Greetings, team. My highest hopes are that everyone is staying safe as we continue to live within a new world order. My last edition of Hayes on the Health Plan was published in April when life with the coronavirus was brand new. In that post I wrote tips on how to work from home effectively.
Since then, my colleagues and I have written numerous articles about our organization’s efforts to adapt to life with the virus. We have also published stories about departments within Texas Children’s Health Plan that are exceeding expectations in phenomenal ways. Speaking of phenomenal, we think it’s pretty phenomenal that our newest department – only five months old when the virus hit – has continued to grow and thrive in spite of a global pandemic. Today, I want to introduce you to the newly created Department of Pharmacy.
Director Peter Peter recently took the time to answer a few of my questions. His answers give us an inside view into the work his department does to keep members healthy, operations efficient and costs manageable.
Q: What is the role of the Pharmacy Department at Texas Children’s Health Plan?
A: Director of Pharmacy is a new position, as my predecessor was overseeing both Quality and Pharmacy. Historically, pharmacy at the health plan was seen as a clinical role focusing on medication appeals and provider outreaches. Under my leadership, it is more of an operations role. My department is responsible for overseeing pharmacy benefits for all our members. We also oversee Navitus, our pharmacy benefits management company. In addition, we partner with the Medical Policy team to make sure that medications processed through medical benefits are configured in compliance with the Texas Medicaid Providers Policy Manual (TMPPM). In addition to clinical, there are significant compliance, quality, financial, advocacy, and innovation opportunities that exist within the Health Plan, Texas Children’s system and Texas Medicaid. The health plan is in a unique position because of its access to the hospital system, care coordinators, medical data, and community status compared to other managed care organizations.
Q: How big is the Pharmacy Department and what are the roles of the employees?
A: We are a team of two. I started as the Director of Pharmacy in October 2019. Jerry Wong is the Managed Care Pharmacist, and he started June 2020. I am looking to expand the department with several more employees. The specific roles are still being finalized, but will focus on data analysis, project management, interdepartmental coordination, auditing, and clinical program development. I’m also looking to consolidate some tasks that are currently being handled outside of the pharmacy department.
Q: How does the Pharmacy Department work with the Pharmacy Department at the hospital?
A: There are several opportunities to coordinate with our hospital and retail/specialty colleagues on various clinical and quality related projects. Examples include coordination of care, identifying system savings, and prescriber education. This is an area I am looking to sync with more after staffing up the pharmacy department at the health plan.
Q: What successes has the department had in recent months, weeks? Especially in light of the pandemic?
A: We were able to successfully lobby the state to make formulary changes when COVID-19 shut down Texas to allow members expanded access to medications. We also identified opportunities where members were taking a brand-drug when generic alternatives existed. We launched campaigns to notify prescribers of these opportunities, which have already resulted in significant savings for the system.
Q: What is the vision for the department and what is the greatest work ahead of the department?
A: Combining medical and pharmacy data is what Amazon, Walmart, CVS, and other health care organizations are racing to, but what the health plan already has in house. We are ahead in this regard. However, the greatest work ahead of us is focused on alternative payment models where pharmacies can encourage pharmacist-prescriber collaboration, improved care coordination, reduction in adverse medical outcomes, and overall savings. There are also significant opportunities to partner with the Texas Health and Human Services Commission to expand traditional “pharmacist” services and have them more involved as partners in the overall care of the member.
Q: Any fun facts or things that people would be surprised to know about this department?
A: The pharmacy department oversees pharmacy benefits for over 400,000 members enrolled in STAR, STAR Kids, and CHIP across Texas.